The “seamless” integration of a collection of information systems has
been recognised as vital in promoting and realising the collaborative aspects
of work. This emphasis on the collaborative role of integration supplements
other studies in CSCW focusing on more singular tools for collaboration. Empirically,
we analyse the design and use of an electronic patient record system (EPR) in
large hospitals in Norway. We discuss the conditions for and types of
integration of EPR with the host of related information systems in hospitals.
We formulate design principles for the integration of collaborative information
systems based on a pragmatic study of the productive role of redundant,
fragmented and ambiguous information.

1.Introduction

A by now thoroughly re-iterated lesson is how coordination,
communication and sharing of information in organisations is inhibited by the
proliferation of non-integrated, incompatible information systems (McNurlin and
Sprague, 1997; Schmidt and Bannon, 1992). Clearly, collective work in
organisations presupposes a minimum of compatibility of understanding and
practices. Incompatibility among information systems arises from differences in
scope, use and responsibility across sites and organisational units and
spawning counter-measures, i.e. strategies of integration. Despite prolonged
efforts, it is fair to hold that “integration has been the Holy Grail of MIS
since the early days of computers in organisations” (Kumar and van
Hillegersberg, 2000:23). A pregnant and relevant expression of how integration
is expected to enhance collaboration is embedded in the recent interest into
Enterprise Resource Planning (ERP) systems as they “promise the seamless
integration of all the information flowing through a company” (Davenport,
1998:121). Despite early awareness of the collaborative aspects of integrated
information systems (Schmidt and Bannon, 1992:21-22), a substantial fraction of
studies within CSCW has focused on singular tools, artefacts, protocols and
coordination mechanisms. Our focus on the collaborative aspects of integrating
information systems feeds into the revitalisation of this early agenda (see
also Hartwood et al. 2001; Symon, Lang and Ellis, 1996).

Strategies and approaches to integration vary (Hasselbring,
2000) and include technical solutions like federated database systems, World
Wide Web and EDI (Grimson et al. 1998:124) as well as Enterprise Resource
Planning systems. In addition, object oriented technologies such as CORBA[1]
and COM[2]
have emerged as a promising way to enable integration, as they are independent
of programming language and operating systems.

Defining technical integration strategies does not, however,
solve the problem related to the mutual autonomy
between the components (Hasselbring, 2000; Sheth and Larson, 1990). In the
following, this is a key aspect as we focus on one approach – historically
influential and currently exemplified by Enterprise Resource Planning systems –
based on a dominant, central database, which other information systems need to
comply to. The modest success to date of curbing fragmentation, redundancy and
heterogeneity of information systems warrants a critical examination of the implicit
and explicit assumptions in the pursuit of “seamless” integration.

Our analysis is aimed at addressing the following set of
issues: how do users cope with non-integrated information systems; what are the
“costs” and benefits in practise of information systems that are fragmented and
contain redundant information; to what extent should such core systems subsume
and include other information systems; under what conditions is redundancy of
information productive. The overall ambition of this paper is to provide
guidelines for the design of integrated information systems aimed at supporting
collaborative work practices. This amounts to specifying the conditions; extent
and nature of integration taking into account the role of redundancy and
fragmentation in practical, everyday, collective work settings. We pursue these
issues through a particular instance of this problem, namely a study of
electronic patient record systems (EPRs; or synonymously computer based
patient/ health records, CPRs). This paper is drawn from the ongoing,
large-scale Medakis project promoted by the Ministry of Social affairs in
Norway establishing EPRs (dubbed DocuLiveEPR) at the 5 largest hospitals in the
country[3].
Exactly as with Enterprise Resource Planning systems, EPRs in large hospitals
are expected to promote collaborative work configurations by integrating
information and information based processes across departments, among different
types of users and over time (Hartwood et al. 2001; Grimson, Grimson and
Hasselbring, 2000). Currently, hospitals typically have an abundance of poorly
integrated information systems including patient administrative systems,
laboratory systems, specialist systems of numerous kinds, a range of sensory/
graphical input devices such as X-ray, ultrasound, EKG and computer-tomographic
images together with paper based records and indices (Grimson et al., 1998:124)[4].

Despite a series of heavily funded national and
international initiatives, there is only very modest success in establishing
working EPRs in large hospitals.Oddly
enough, there does not seem to exist any systematic, comprehensive and critical
evaluation of these efforts (although more narrow or restricted ones exist; see
Massaro, 1993; Kushniruk et al., 1996; Safran et al., 1999; Sands et al., 1995;
Lærum, Ellingsen and Faxvaag, 2001). EPRs have repeatedly been identified as
“essential” (Dick, Steen and Detmer, 1997) or “at the heart of the application
of IT in health care” (Grimson, Grimson and Hasselbring, 2000:50). It has,
however, proved remarkably difficult to achieve “seamless” integration and to
establish more than fairly isolated pockets of use (Berg, 1998; Levitt, 1994;
Szolovits et al., 1995).

In section 2, we
briefly outline the collaborative aspects of integration of information
systems. We discuss how the strategies of integration for management
information systems, for EPR in general and for DocuLiveEPR in particular share
important similarities, namely privileging centralised solutions. Section 3
describes the setting of the case and reflections on the research design. In
section 4 we present three case vignettes containing illustrations of
collaborative work with and around DocuLiveEPR. Section 5 analyses the
conditions for collaboration through “seamless” integration. It is structured
along two dimensions – integrated/ non-integrated systems and identical/
related but similar information – and aimed at identifying the “costs” and
benefits of the 2 x 2 generated matrix of situations. Section 6 contains
concluding remarks including guidelines for design of “seamlessly” integrated
information systems in collaborative work settings.

2.Collaborative
work and the integration of information systems

In an effort to highlight the similarities, we outline the
collaborative aspects around integration of information systems at three
levels: the general level of management information systems (MIS), the level of
EPRs in general and a specific instance of an EPR represented by DocuLiveEPR.

2.1.Management
information systems (MIS)

The source of the problem with non-integrated information
systems and subsequent hampered organisational communication is hardly news. It
follows immediately from

“incompatible data definitions from application to
application, department to department, site to site, and division to division”
(McNurlin and Sprague, 1997:198).

This incompatibility, stemming from distinct situations of
use, is identified as a key challenge for enhanced collaboration in
organisations – and the problem where tighter integration is perceived as the
solution (Davenport, 1998; Hartswood et al., 2001). In principle, one approach
to integration is a non-centralised one with interchangeable components;
modules and objects similar to middleware software like CORBA, COM or like the
Internet suite of protocols (see above). In practise, however, an approach
based on a central, comprehensive database as found in Enterprise Resource
Planning systems is often compellingly attractive as “the promise of an
off-the-shelf solution to the problem of business integration is enticing”
(Davenport, 1998:121). SAP, the world’s leading vendor of such systems,
advocates their product as a way to enhance collaboration across functional
boundaries:

“SAP R/3 overcomes the limitations of traditional
hierarchical and function-oriented structures like no other software. [All the
functions] are integrated into a workflow of business events and processes
across departments and functional areas” (www.sap.com).

Rephrased into the vocabulary of systems integration
(Hasselbring, 2000), approaches with one dominating component, which the others
have to comply to, are attractive to many.

2.2.Electronic
patient record systems (EPRs)

The discourse around collaboration and the integration of
information in connection with ERPs mirrors exactly the more general and
long-standing debate in management information systems and Enterprise Resource
Planning systems outlined above (Hartwood et al., 2001; Hanseth and Lundberg,
2001). Perfectly aligned with the arguments for Enterprise Resource Planning
systems, the project Synapses funded by the European Union points out that:

“[U]sers
performing diverse tasks (...) [in] different department within a hospital may
have deployed different (...) systems that should be integrated in order to
support the business processes adequately” (Grimson, Grimson and Hasselbring,
2000:52-53)

Similarly, the W3 EMRS project (1995) sponsored by the
United States National Library of Medicine aims at:

“tam[ing] the Tower of Babel in current medical
databases [by] defining a common medical record (...) [that enables] meaningful
queries across patient information databases in multiple hospitals”

As for the more general case of management information
systems, there are, in principle, different routes to the integration of
information systems in hospitals. Yet, EPRs are – and have been for some time
(Dick, Steen and Detmer, 1997) – perceived as essential in achieving this
integration; EPRs are the nexus for
integration. To illustrate this mode of thinking, Szolovits et al. (1995: 16)
explain that it implies:

This emphasis on the role of the conceptual model with
associated interfaces has been heavily advocated also by the European
standardisation organisation, CEN TC 251 (prENV13606 1-4, 1999).The
problems with fragmented and non-integrated information systems in hospitals
have largely spawned approaches building on abstracted and highly idealised
models of clinical work as a result of premature standardisation following from
the urge

“to make sure that unsuitable circumstances (e.g.
proliferation of incomplete solutions) are not allowed to take root…[so]
standardisation must be started as soon as possible in order to set the
development in the right track” (De Moore, 1993:4).

2.3.DocuLiveEPR

A key concern in the Medakis project has been the role of
DocuLiveEPR in relation to the rich variety of other information systems, in
other words, the strategy of integration. The crucial problem – reiterating the
theme from management information systems and EPR in general – is the
proliferation of local, tailored and non-integrated information systems and
their apparent hampering of collaboration.

In the requirements specification worked out in collaboration
between the vendor and the hospitals, the presence of special purpose
information systems is recognised. This produces fragmentation as:

“There is a
tendency that the specialist functions create their own information system to
store and systematise data. In Norwegian hospitals today, these systems are
only to a limited degree integrated or available in a uniform interface ”
(Unified requirement specification, 1996)

This leads up to formulating a main goal of Medakis:

”to give access to, and produce the documentation
that exist in the paper-based patient record. The EPR should replace many of
the special purpose information systems that exist in the wards” (ibid.)

The basic premise for EPRs, as captured by the Medakis
project specification and documentation, is of course to contribute to an
overall improvement in productivity and quality (Unified requirement
specification, 1996). The crucial element, however, is for the EPRs to function
as the core information system and to

“collect all clinical patient information in
a uniform computer system (…) and offer a common interface to all other
IT-systems” (ibid., emphasis added)

As the more general cases outlined above, integration could
in principle be achieved without delegating a pivotal and ambitious role to
DocuLiveEPR. In practice, however, DocuLiveEPR was delegated a central role as:

“Even an electronic patient
record with a relatively narrow functionality will gain a unique position in a
hospital as it deals with the most sacred information” (M1)

Thus, from the outset the strategy of integration was given
and “the EPR was supposed to be at the centre of information systems in the
hospitals” (L1). Tellingly enough, another important source of information,
namely the patient administrative systems (PAS) was assumed to be subsumed
rather than integrated with the EPR:

“We expected that the EPR
eventually would include the registration functions of the PAS (...) and that
the registration forms of PAS instead became schemas in the EPR” (L1)

Given that PAS contains basic demographic information and
support for budgeting, accounting, resource allocation, planning, waiting lists
for procedures, appointments as well as patients’ visits and stays, this
delegates the central means of integration to DocuLiveEPR.

This is reinforced by the vendor’s current strategy of
subsuming specialist systems by replacing them by EPR controlled modules. As
explained by a senior manager of the vendor:

“Instead of having many
specialised systems you get an ERP that contains modules that can be added when
needed. In this way, you get rid of many specialised systems from different
vendors that otherwise had to be integrated (...) [hence] it is planned a PAS
module in the next version of DocuLiveEPR” (S1).

3.Methodological
considerations

3.1.Setting of the
study

The Medakis project of the Norwegian health authorities has
a long history (see (Ellingsen and Monteiro, 2001) for details), but has run
since 1996 with Siemens as the privileged vendor. The DocuLiveEPR system,
developed as part of the Medakis project is used to an interesting extent,
especially at the regional hospital in Tromsø (RiTø) and the regional hospital
in Trondheim (RiT). These two hospitals have used DocuLiveEPR for the shortest
time (since February 1999), but nevertheless with the most widespread use among
the five regional hospitals (Lærum, Ellingsen and Faxvaag, 2001)[5].
Both RiT and RiTø have completed their installations of DocuLiveEPR. Aligned
with the development strategy, the users are currently primarily physicians and
secretaries. Computer availability is reasonable for these two groups. The 5
regional hospitals together have about 6000 defined users of DocuLive EPR. On a
normal working day, there are approximately 1400 concurrent users. A rough
estimate suggests that there are about 2,5 million electronic documents, mostly
physicians’ notes but also sick notes and prescriptions. It is possible to
import certain information from the patient administrative system (PAS) into
DocuLiveEPR, but not the other way around[6].
With the upcoming (v5.0) version, the laboratory systems will be integrated and
accessible through DocuLiveEPR. DocuLiveEPR also includes a workflow module
that is strongly encouraged by management. A principal function here is the
(digital) signing of notes by the physicians.

3.2.Data collection
and the process of interpretation

This study belongs to an interpretative approach to the
development and use of information systems (Klein and Myers, 1999; Walsham,
1993). Although broadly oriented within this tradition, this study is shaped by
our analytic affinity with science and technology studies (STS) in general and
actor-network theory (ANT) in particular (Latour, 1999; Bowker and Star, 1999).
Traditionally and predominantly, employed as a vehicle in historical reconstructions,
ANT is increasingly used as we do here to also make sense of unfolding,
real-time practise in much the same way as ethnographic studies (see Berg,
1999; Knorr-Cetina, 1999; Timmermans and Berg, 1997).

We rely on four types of data: participative observations,
interviews, documents and informal discussions. The participative observations
by the first author took place during two periods (February 2000 and January –
February 2001) at the University hospital of Tromsø (RiTø) resulting in 61
hours of observations. During the observations, 105 pages of handwritten notes
were taken and subsequently transcribed. Photographic documentation highlighted
work situations of particular interest. Additional reflections, comments and
questions were added to the notes, resulting in 45 pages of documentation. The
observations were especially aimed at work situations involving physicians as
they are recognised as a particularly important user group for the success of
the Medakis project, but nevertheless often included secretaries, nurses as
well as patients. Questions were posed to clarify and elaborate observations to
obtain the kind of background understanding that is emphasised by Klein and
Myers (1999). The extent and format of these obviously varied with what was
possible without intruding too much with the ongoing work, often postponing
them to less hectic periods.

We have conducted 27 in-depth semi- and unstructured
interviews with users (coded as U1-U16), Medakis project members (M1-M6), EPR
lobbyist prior to the Medakis project (L1-L2), policy and decision makers
(D1-D2) and senior management of the vendor (S1). Through students the second
author has supervised, we have also had access to 12 transcribed interviews
with the vendors. These have been used for background information only.

We have had access to a number of electronic and paper based
documents. We have gained access to two, comprehensive archives belonging to
two of the key actors among the policy and decision makers. Firstly, the
Norwegian Research Council, a principal sponsor of EPRs in the years
immediately preceding the Medakis project, and, secondly, KITH (centre for IT
in health care), a publicly owned agency aimed at establishing IT related
standards in Norwegian health care. In addition, we have had detailed access to
contracts, memos, specifications and documentation within the Medakis project.

In striving to adhere to Klein and Myers’ (1999) principles
of multiple interpretations and suspicion, we have relied heavily on validation
through iterated discussions with 25 involved actors challenging our
interpretations: 3 policy and decision makers; 8 users; 1 EPR lobbyist prior to
Medakis and 13 Medakis project members.In addition, earlier versions of this paper have been circulated and
discussed with these involved and engaged actors who provided extensive
feedback, which in one instance resulted in 12 pages of written comments.

Klein and Myers’ (1999) principle of interaction between
researchers and the field raises highly relevant concerns about how we were
conceived and how our roles influence our interpretation. Neither of us were
perceived as detached observers as the first author used to be part of the
local Medakis project organisation in Tromsø and the second author is heading a
research project assessing EPRs in Norway through an emphasis on the Medakis
project. This has involved a delicate, and at times problematic, balance
between engaging constructively in debates with the Medakis project members at
various levels while simultaneously keeping a critical distance.

Medical practice varies enormously across different domains,
departments, hospitals and countries (Atkinson, 1995; Strauss et al., 1985;
Berg, 1998; Grimson, Grimson and Hasselbring, 2000). We have no ambition of
paying justice to this variation in any systematic or comprehensive manner.
Rather, we merely aim at motivating for an appreciation of this variation
through a sampling of 3 wards at RiTø. This variation in practice also
translates into a corresponding variation in the use and type of information
sources. Characteristic features of the work situation in the wards are

1.Outpatient
clinic, Dept. of Medicine: a hectic environment marked by a constant
improvisation to cope with unplanned events (and patients). As a result, much
of the clinical record keeping takes place in parallel, not finishing one
patient before attention needs to be shifted to the next.

2.Department for
Eyediseases: a largely self-contained department conducting highly specialised
work. This takes place with relatively little interruption and interaction with
other wards at the hospitals, promoting an emphasis on research oriented
activities.

3.Department of
Rheumatology: dominated by chronic patients that require extensive, collective
and inter-disciplinary discussions among the health professionals rather than
instantaneous, individualistic decision-making.

4.1.The outpatient
clinic: improvisation and fragmentation

The Outpatient clinic is an integral part of the rest of the
Dept. of Medicine. Hence, they have responsibilities for patients already at
the hospital as well as those arriving. Only the secretaries and nurses are
assigned to the Outpatient clinic on a permanent basis. Admittance is
predominantly based on referrals (i.e. letters) from local general
practitioners. Other patients turn up for scheduled checks following a period
of hospitalisation. The offices in the Outpatient clinic are small and crowded,
implying that they are often shared among different user groups. To illustrate
the work of physicians and their use of information sources, consider the
following vignette involving the chief physician.

His
office contains two desks, containing 12-15 stacks of paper-based, patient
records and a computer (see figure 1). On the shelf above the desks, there is
an additional stack of patient records with a yellow post-it label stating “to
be signed”.

Immediately
upon entering the office, he starts looking for a specific patient record,
calling out “Where is it? I was just working on that record”. He leaves the
office to inquire at the secretaries’, but quickly gives up and instead starts
to dictate reports from one of his own consultations. He examines the
EKG-printouts turning them back and forth while continuing to dictate. He
studies the physicians’ text notes in the patient record, and alternates by
looking in the notes and dictating. He turns to the computer and logs onto the
PAS system to check laboratory results through an established interconnection
between the PAS system and some of the laboratory systems.

He
selects an A4 paper form and enters values from a myocardial scintigraphy
procedure. He fills in why and how the investigation was done, the result, and
its impact on his final assessment of the handling of the patient. When he is
done, he places the form in a paper archive on the shelf immediately above him.
The chief physician and one of his colleges use this archive both as an element
in their product quality system and as material for their research. This paper
archive has been used for eleven years and contains almost 1900 patients.

Logging
onto DocuLiveEPR, he activates his personal working list (part of the workflow
system) and locates the appropriate patient record. Frustrated by not finding
an electronic record for a blood test, he turns to the paper record, hoping
that a note has been included. Still without any luck, he turns to the PAS
system to continue his search. Upon finding it, he inserts paper in the empty
printer and prints it together with 2 previous results from the same patient.
He places the three copies in a sequence on the desk in order to assess
possible progress of the results. Next, he picks up a small picture and studies
it. It is a nuclear medical examination. By now his desk is covered with
several text notes, the renogram and 3 A4 sheets of blood results. Appearing in
different windows on the screen, the patient’s information is showing in both
DocuLiveEPR and in the laboratory system. He proceeds by typing his final
evaluation into the policlinic note in DocuLiveEPR, about 6-7 lines of text and
signs it electronically. To finish, the paper based patient record is extended
with a letter, a post-it note, the hard-copy laboratory result from PAS and an
A4-paper-sheet draft. They are all attached to the front cover of the patient
record with a paper clip.

Someone
from the accounting department is on the phone requesting help to change diagnostic
codes. The ICD[7] and NCSP[8]
codes are stored in the patient record but also in the PAS. But these codes
take on quite distinct meanings in these two contexts of use. In the patient
record, the ICD codes relate to the care and treatment of the patient and are
the basis for subsequent discharge letters. In PAS, however, the ICD codes are
used in a carefully designed way as the basis for governmental reimbursement
according to the US adapted DRG[9]
coding scheme. If the ICD coding fails to translate into the predefined DRG
scheme, the hospital will not be reimbursed.

The
accounting department routinely checks the validity of the codes and reports
back to the wards about errors or other reasons to make modifications such as
the last phone call. RiTø estimated a loss of 15MNOK in 1999 due to “incorrect”
ICD/DRG coding. As the consultant from the accounting department explained to
us afterwards, they requested this particular chief physician to make the
changes in the ICD/DRG codes in PAS because they knew he was willing and “quick
in the head”.

4.2.Dept. for
Eyediseases: stability and specialisation

The Dept. for Eyediseases has ten affiliated physicians and
is fairly self-contained. There is little need for laboratory results and X-ray
examinations. Typical patients groups are those related to age, diabetes and
circulatory disorders as well as lens disturbances such as cataract, a disease
often leading to surgery. Again, we present a vignette to illustrate the work.

After
having seated the patient, an elderly woman, in the examination chair the light
is turned off. Two physicians are present, the head physician and an assistant
physician. In preparation, the head physician has read the paper-based letter
of referral as well as the patient’s paper-based patient record. He has
interviewed the patient and obtained relevant background information.

A
digital retina camera is placed between the patient and the physician. The
camera is connected to a near-by computer, which runs a digital image
processing system called OcuLab. OcuLab is used to process black and white
pictures that are transferred from the camera and subsequently stored on a
networked server (Figure 2).

Figure 2 The laser room with
the assistant physician placed in the patient’s position.

Behind
the patient, there is an archive of negatives of colour pictures. The use of
this archive has been reduced after the introduction of OcuLab. But it is still
in use, especially in situations where a colour photo may explain more than
black and white photos, for instance, in identifying leakage from the blood
vessels.

The
patient’s pupils have been pharmacologically enlarged to ease the inspection of
retina. On her right arm is placed a syringe in which the assistant physician
injects contrast fluid. After approximately 10 seconds, the fluid reaches the
eyes. The head physician studies the patient’s pupil through the camera. He
starts taking a sequence of pictures with intervals of one second. After a
while, the pictures slowly appear one by one on the computer screen. Already in
the first picture it is possible to see abnormal blood vessels. They briefly
discuss if they need to proceed but quickly agree that it is unnecessary.

Up
till now the computer has processed about 40 pictures. Just a few of them need
to be stored for future usage. The head physician makes his selection, stores
these and discards the rest.

He
logs off OcuLab and the examination is over. Had it been necessary, this is
when colour pictures would have been taken, but with a different camera. He
immediately dictates the result of the examination on his tape recorder. A
secretary will subsequently type this into DocuLiveEPR, for the physician to
electronically sign afterwards.

A
possible further action for the patient is to receive laser treatment in the
adjacent laser room. In these situations, the physician will use OcuLab to
retrieve the pictures of the patient on the computer screen. To burn the laser
marks correctly in the retina, he would be aided by the pictures from OcuLab.

In
the laser room, the patient’s record is usually placed on the shelf right
behind the patient. Next to it, there is a large logbook that contains
information about patients treated with this equipment containing date, type of
treatment, anaesthetic used, result and responsible physicians. In addition,
there are corresponding logbooks in the ward’s other laser room and the surgery
room. This information is used on a regular basis to report the activity in the
ward, both internally and externally to the administration of the hospital. The
information in the log-books overlaps with corresponding information in the
patient record, but formatted to promote the readability of accumulated data.

If
a cataract operation is necessary, an artificial crystalline lens is placed
over the eye by the surgeon. Attached to each lens is some technical
information (producer, model, length and serial number) about the same size as
a post-it note, which will be glued to the patient’s record to document which
type of lenses was used.

The
Dept. for Eyediseases participates in an international cataract research
project. In connection with cataract surgery, a special paper form is filled in
and archived. The ward is in the process of developing a new database system in
collaboration with the IT-department. The system is to handle information
obtained prior to, during and after cataract surgery. Printouts from this
system will be placed in the paper based patient record. The chief physician in
the ward emphasises the local context of use:

The cataract record is made for
specialists, which means that this information is meant for insiders and nobody
else. And unlike an ordinary free text note in the patient record, the cataract
record contains predefined categories for ‘no remarks’, ‘ok’ and numbers. This
information is possible to measure and process statistically afterwards

4.3.The Dept. of
Rheumatology: the collective effort

Dept. of Rheumatology is a medium-sized ward at RiTø
consisting of 23 beds served by cross-functional personnel: physicians, nurses,
physiotherapists, ergo-therapists and social workers. There are a vast number
of different rheumatological diseases, which combined with its gradual
character and fluctuating symptoms often prohibits exact diagnosis at an early
stage. This implies that the personnel have to deal with uncertainty. The ward
has a lot of chronic patients. The vignette that follows illustrates the mode
of work in the ward.

This
Friday morning, 10 physicians are present at the previsit meeting. Everyone
brings their paper notes and makes additional ones as they discuss the latest
about the patients. On the table, there are stacks of patient records. Some of
the records are very thick, up to 15 cm each, as the ward has a lot of chronic
patients. Some of the physicians skim through the patient record. There is also
a book containing nurse documentation on the table. A nurse brings in a booklet
with laboratory results.

After
working through all the inpatients, it is time to discharge patients. Being
predominantly a working day unit, most patients are discharged on Fridays. This
creates a lot of work associated with discharges on Fridays with subsequent
admittance the following Monday. Another nurse joins the group with a nurse
patient record and they start discussing the cases more thoroughly. At one
instance, they discuss what to do about a specific patient who regularly
forgets to take her medicines. Based on their different information sources
about this patient (the nurses’ documentation and the physicians’ notes), they
discuss how to cope with the situation. One of the physicians underscores the
importance of taking the prescribed medication while the nurse argues that
pushing medication now is of no value since they are not able to follow her up
after she leaves the hospital.

Nurse:
She forgets to take her medicines.

Physician:
But it’s important that the she takes them!

Nurse:
Why bother? She forgets it anyway when she returns home.

Physician:
She has all signs of depression and has been suicidal.

The
group studies the patient’s chart containing important information during the
stay of a patient (pulse, temperature, blood pressure, medications prescribed
and given). They discuss the current medication. One of the physicians writes
something on the patient chart. The nurse makes some notes on her own paper,
which she later on will write into the nurse documentation. Explaining the role
of nurse documentation, a nurse in the Medakis project points out:

“The
nurses document continuously, 24 hours and from shift to shift. This
distinguishes their documentation from the physicians’ (...) The purpose of the
nurses’ running notes is to make the care of the patient in a dynamic process.”
(U1)

After
a while, the table is covered with paper from the patient records, or more
specifically from the chart book. The chart book contains information about all
the patients associated with this working group. For each patient, essential
information from the patient’s paper record is extracted. The chart book also
contains the patient chart, abstract sheet and laboratory results. There are
also copies of the physician’s text notes that have previously been entered
into DocuLiveEPR. When a patient is discharged, a letter is produced and sent
to the general practitioner. The letter contains a description of the stay but
also functions as a “memory” for the physicians in the ward. However, due to
incomplete information and lacking personnel resources, it often takes a week
(sometimes even longer) before the discharge letter can be produced. To
compensate, a preliminary discharge letter, a so-called discharge form, is produced before the patient leaves.
The discharge form is an A4 paper sheet with several carbon copies. It is
hand-written and very brief containing information to the patient, the general
practitioner and the secretary at the Rheumatology ward. In addition, one copy
is placed in the patient’s record until the formal discharge letter is written.

Discharge
letters from the Dept. of Rheumatology tend to be long due to the chronic
character of the illness. However, detailed discharge letters seem to be only
partially useful for general practitioners, which usually prefer to get answers
as quick as possible prior to getting a complete discharge letter. This is
illustrated by the fact that often the general practitioners only include the
most important parts of the discharge letter in their own EPR system.

Let
us return to the Friday’s round of discharging. Physician A has three patients
to be discharged. To support the writing of the discharge form, she uses
information from the chart book (e.g. laboratory results), consultations
written by other specialists, EKG printouts and physician’s text notes. She
frequently examines the patient-chart and the abstract sheet to get the proper
information for the discharge form. The abstract sheet is an outline for a stay
of a patient and as physician A expresses it:

“It
is a tool for us (…) It contains information about the history of the case, reason
for referral, patient diagnoses, internal referrals, test results, problems
etc”.

The
abstract sheet is also an important tool in the communication with the other
professions in the hospitals, like nurses, physiotherapists, ergo therapists
and social workers and used in interdisciplinary meetings both as a summarised
version of the case and as a place where to put short notes. It is also used as
a mean to provide continuity between shifts:

“The
nurses will go through the abstract sheet in the evenings to check whether
something has to be done” (physician B)

as
well as continuity between the wards because “when a patient is referred to
another ward a copy of the abstract sheet will follow”.

5.Analysis

The lack of integration in hospitals is, and has always
been, a principal motivation for the efforts into EPRs towards “seamless” care
(De Moore, 1993). “The present inability to share information across systems”,
Grimson, Grimson and Hasselbring (2000:49) maintain, “represents one of the
major impediments to progress towards shared care and cost containment”. We
analyse the conditions for and strategies of integration at play around EPRs in
hospitals. Two concerns are highlighted in our analysis, concerns which
underlie strategies of integration. First, we distinguish between cases where
the different sources of information
are integrated or not. Second, we distinguish between the cases where the contents of the information (from the
different sources of information) are identical from the cases where they are
related, but slightly different. This gives rise to the following four types of
situations:

source

Integrated
information

Non-integrated information

contents

Identical information

compatibility

redundancy

Related, but
different

ambiguity

supplementary

5.1.Redundancy
(identical information, non-integrated)

The abundance of redundant information duplicated in
different, non-integrated information sources is a major motivation for the
pressure for integration. It has traditionally signalled potential consistency
or communication problems (De Moore, 1993). It represents the “obvious”
occasion for tighter integration. Before jumping to conclusions about the need
to integrate, it is instructive to analyse how practitioners cope with
redundancy. Only through an appreciation of this may reasonable strategies for
integration be formulated.

An immediately and striking first observation is the
relative modest level of problems actually caused by redundancy. On the
contrary, there are a rich set of artefacts and routines that perform the
invisible work, fill in the gaps and glitches (Gasser, 1986; Bowker and Star,
1999; Latour, 1999; Atkinson, 1995). Users are highly competent in bridging
these gaps. In her studies of control rooms, Suchman (1993:119) underscores how
collaborative work draws on different information sources as “work in
operations makes artful use not only of computer technologies, but of a range
of other communications and display technologies as well”.

A particular instance of redundancy is that between paper
and electronic form. There are several studies that focus on the physical
properties of paper and the way this afford a number of effective and flexible
capabilities in clinical work (Nygren and Henriksson, 1992; Luff, Heath and
Greatbatch, 1992; Harper et al., 1997). At the Outpatient clinic in our study,
the paper folder in the paper-based patient record integrates the various
notes, texts, pictures and printouts in such a way that redundancy of
information is worked abound by sifting through duplications.

Beyond working around redundancy in the manner outlined
above, Hutchins (1994:223) argues for a productive role played by redundancy as
a principal reason for the robustness[10]
of work because if “one (...) component fails for lack of knowledge, the whole
system does not grind to halt”. Going back to the Department for Eyediseases,
the overlapping of (ordinary) colour pictures, electronic black and white ones,
the notes in the logbooks, avoids making the work vulnerable to the failing of
any one of these.

This all adds up to demonstrating that redundancy is not
necessarily and automatically the kind of problem portrayed in traditional
management information systems. This should not, however, be misconstrued as an
argument that any redundancy is acceptable. It is merely the argument that the
pros (largely by-passed) and cons need to be assessed before judgement is
passed. The episode from the outpatient clinic (section 4.1) where the
physician searches for the laboratory results demonstrates how redundancy of
information – presenting the test results in DocuLiveEPR, in the paper-based
patient record or in the laboratory system accessed through PAS – enables him
to conduct his work even if he did not find the test results immediately.
Turning around in his chair, logging onto a different non-integrated system he
locates the information. After locating it, he prints the results and includes
a copy in the paper-based patient record thus filling the glitch. Yet, the fact
that he is able to bridge the gap and maintain the redundancy is not an
argument for preserving the situation. As pointed out above, design decision
regarding redundancy need to assess both costs and benefits. In the present
case, the benefits (robustness) do not compensate for the amount of work
involved in maintaining the redundancy. Hence it seems reasonable to require
the laboratory results to be tightly integrated with DocuLiveEPR[11].

5.2.Supplementary
(related information, non-integrated)

These types of situations resemble those analysed above but
are distinguished by the fact that the information in the different information
systems is not identical only “related”. Obviously, there are problematic cases
of separating these two situations. Typical illustrations of the present type
include situations where the different professions have different versions of
patients’ trajectories or were one version is an abbreviation of another. The
task is to pragmatically assess how users cope with information that is closely
related, partly duplicated but distributed across different information systems
or even within the same system. As in the case above of redundancy, we hope to
demonstrate that supplementary information plays an often overlooked,
productive role that warrants closer scrutiny. We accordingly need to analyse
its role in collaborative work settings.

The Dept. of Rheumatology represents a typical illustration
of the present type of situation where the physicians, nurses and
physiotherapists work together discussing each patient. The different
professions have their own documentation that slightly overlaps with the other
professions’ documentation, which they refer to in their spoken performances
(Atkinson, 1995:91).The episode
outlined in section 4.3 with the forgetful patient illustrates the role of the
related but different information (the nurses’ documentation and the
physicians’ notes). It illustrates an important characteristic of the work at
the department, namely how decisions are negotiated among (and within) the
professional groups based on their related, but different written accounts. As
one of the physicians pointed out:

“Rheumatology is a kind of oral
and assessing profession (…) it is important to have meetings, discussing which
treatment that is most important or correct [and] whether it should change or
not”

This is closely related to what Nonaka and Takeuchi (1998:230)
denote ‘learning by intrusion’, a mechanism for promoting collaboration which
implies the

“existence of information that
goes beyond the immediate operational requirements of each individual. The
redundant information enables individuals to invade each other’s functional
boundaries and offer advice or provide new information from different
perspectives.

In her recent book, Knorr-Cetina (1999) makes a similar
observation when she explains how knowledge work presupposes information in
different, related formats to enable the necessary “narrative encapsulation” of
knowledge. Collaboration and mutual understanding presupposes “the general
strategy of mixing together [results] from very different origins in an attempt
to come to grips with the limitations of specific data or approaches”
(Knorr-Cetina, 1999:76). Hence, both Nonaka and Takeuchi (1998) and
Knorr-Cetina (1999) underscore the productive role in relation to collaboration
of this kind of supplementary information.

Supplementary information, related but different versions
that are not integrated, also allows for competing agendas as the case of
discharge letters at the Dept. of Rheumatology illustrates. General
practitioners often prefer rapid answers at the sacrifice of completeness, thus
conflicting with the need for the physicians at the ward to use complete
discharge letter in reconstructing the case when the patient reappears at the
ward. Today, the discharge form functions as a convenient boundary object
(Bowker and Star, 1999) serving both of the communities: rapid responses for
the general practitioners and accumulating experiences for the hospital
physicians

Another example, also from the Dept. of Rheumatology, is
their actual use of the abstract sheet in their daily operations. It provides
supplementary – abbreviated, condensed – information. Given the vast volume of
documentation associated with chronic patients dominating the ward, summaries
represent essential, supplementary information, particularly across different
communities of practise (or professions).

“The abstract sheet is very
useful in achieving quick overview of the case. It contains an extract of the
status from the patient record as well as brief notes from interdisciplinary
meetings. Then we don’t need to go back to the patient record (...). It also
outlines what has happened and what is planned” (physician A)

Another aspect of supplementary information is that it
allows collaborative needs and interests to be tailored to local, situated
contexts of use as illustrated by the proliferation of local archives and
indices. In the three wards, there were archives for quality insurance of a
specific procedure (outpatient clinic), colour picture backup archive (Dept.
for Eyediseases) and research related archives. For instance, the Dept. for
Eyediseases is involved in developing an IT-based cataract surgery archive. The
reason is that DocuLive EPR does not include the flexibility to manage all
their special needs, especially regarding accumulated
data, reports and quality assurance (see section 4.2).

Combining information from multiple, sometimes independent,
sources of information permits consistency check of multiple representation
with each other (Hutchins, 1994:35) or “framing” as denoted by Knorr-Cetina
(1999:72) as it serves to check, control or extend information from different
non-integrated sources. This was the case for the cataract surgery research
project at the Dept. for Eyediseases. The participants of the research team
perceived the quality of the codes in PAS as not sufficient for their purposes
and accordingly created their own research database maintaining their own
diagnose and procedure archive.

In sum, we have pointed out and argued for the productive
role supplementary information plays in facilitating robust, collaborative work
configurations (establishing shared understanding, allowing local flexibility
and performing consistence checks). These benefits, we argue, tend to override
the costs associated with maintaining this supplementary information, implying
that the inclination towards tighter integration should be curbed.

5.3.Ambiguity
(related information, integrated)

A well-known aspect of technology is how it may be interpreted,
conceived of or used differently across distinct local situations (Blume, 1991;
Barley, 1986). Hence, notions like interpretative flexibility (Pinch and
Bijker, 1989), boundary object (Bowker and Star, 1999) or situated action
(Suchman, 1987) all, in slightly different ways, underscore this. To merely
reiterate this for EPR is accordingly hardly news. We want to pursue this
further by spelling out how these differences in use feed into the
coordination, delegation and organization of work (Berg, 1999). This amounts to
tracing the productive role of the ambiguity in interpreting and using this
information.

Many have pointed out how medical work in general and
patient record keeping in particular get caught up in an increasing number of
roles (Berg and Bowker, 1997; Bowker, Timmermans and Star, 1995). Beyond a
resource for diagnostic purposes, it functions as a vehicle for coordinating
work, as a source for cost- and income generation and become relevant for
insurance companies.

The example from the Outpatient clinic in section 4.1 of how
ICD codes, appearing first in DocuLiveEPR before being registered in PAS,
illustrates this. The difference across the communities of practise should be
clear: the economical incentive of management vs. clinical-diagnostic
motivation among the physicians. This explains why there are, as so
compellingly demonstrated by Bowker and Star (1999), competing agendas and
accordingly difficulties in making them unique. In addition, had the ICD/DRG
coding been uniquely defined across the PAS and DocuLiveEPR, this would have
generated additional work for the physicians. If the ICD codes were identical
in both systems, any changes of coding would have to be carried over to patient
record as well. This includes, for instance, the discharge letter that is sent
to the general physician. This is by no means a straightforward task as nothing
that is signed by a physician can be changed. The changed code would have to be
written to DocuLive before sending new copies to the general physician with the
updated codes. From a clinical point of view, this work is irrelevant as it
only relates to economy.

The coding of ICDs is not necessarily “wrong”, but has to be
continuously updated according to new guidelines from the Ministry of Social
affairs or misplaced main and secondary diagnoses. Often these aspects
influence reimbursement. As the accountant explains:

“We correct codes regularly (...)
[and] the Ministry of Social affairs acknowledge that the hospitals can correct
these codes going back the whole year. For instance, in September, new
guidelines were issued that were supposed to be valid already from January 1.
the same year”.

An observed example from RiTø is the sequence of the two ICD
codes C91.0 and Z51.1. The former expresses a type of cancer while the latter
expresses appearance to chemotherapy related to the disease. Before the change,
with C91.0 as the main diagnose and Z51.1 as the secondary, no reimbursement
was generated. After correcting, i.e. swapping the sequence of the two, the
reimbursement produced 11952 NOK.

Another example has recently surfaced related to the
surgical departments. Partly by luck and partly by chance it has been
discovered that the hospital had missed reimbursement through the lack of
coding of “cutting time”[12].
Cutting time that exceeds 3 hours is entitled to a larger amount of
reimbursement. Adding these procedure codes in retrospect will increase
reimbursement with ½ MNOK a month.

In the Medakis project there has been a heated disagreement
about how to make PAS and DocuLiveEPR interoperate. The issue circles around
which of the two should be delegated the status as a "reference
system", i.e., which should dominate the other whenever inconsistent
information existed across the two, integrated systems. This disagreement
surfaced in one of the Medakis project groups in 1998 where the hospital
participants wanted to maintain the role of the PAS as the primary repository
for some part of the information to comply with earlier days. The memo from the
working group states that:

“PAS is a reference system for
defined patient administrative information, like demographic data, diagnostic
codes and so on. This means that the information in the PAS system at any time
is taken to be the most correct” (Workgroup II, 1999: 3)

To avoid being ignored, the hospital participants really
pushed the integration issue. The resulting document underscores that PAS must
be seen as a reference system (rather than DocuLiveEPR) and that access to this
system shall be done by the use of a COM interface. The end result, however,
has been to promote DocuLiveEPR as a centralised system, including its planned
PAS module. This reiterates the theme outlined in section 2, namely that even
if non-hierarchical integration is conceivable in principle, more often than
not a centralised mode of integration is privileged.

This centralised approach to integration of information
systems ban systems adapted to more local use, including the option to change
coding scheme as illustrated above with DRG.

This example is not exceptional. Participants in clinical
research often perceive that the quality of the diagnostic codes in PAS and
even in the patient records are insufficient for their research projects and
henceforth create their own clinical research databases where they maintain
their own diagnose registers. These codes are also compared to the actual
patient record text in order ensure the right quality. The former head of the
clinical research department underscores this:

“If you base clinical research
solely on diagnose codes from the patient record [and PAS] then the validity
will be challenged as it is well-known that the quality of these codes is poor
(...) it was bad also before DRG was implemented[13],
but has since deteriorated further (...) as the physicians are under pressure
to code to maximise reimbursement”

This goes to the heart of their problems as it is essential
to select patients belonging to certain diagnose categories in their research.
This spawns local improvisation:

“You may wonder, then, how it is
possible to locate the patients when it is not possible to use the diagnose
codes! We cope by using the laboratory results (…) [as index and subsequently]
read through the patient record text in order to see what this is all about ”

An additional point that influences the perceived quality of
coding and the danger of integration is changes over time:

“The categorising of the diagnose
codes is in continuous change and the clinical picture for a disease get new
definitions. For instance: what you define as a heart attack today is not
identical with the definition 5 years ago.”

Counter-intuitive for many perhaps, ambiguity is often the
basis for a sound division of labour. Referring to the case discussed above
regarding the ambiguity of coding, the benefits are, we argue, greater than the
costs, implying that forcing compatibility by flattening ambiguity is
dysfunctional.

5.4.Compatibility
(identical information, integrated)

These situations are represented by those instances where
“seamless” integration is indeed achieved. They are included for the sake of
completeness. An illustration from the Outpatient clinic is when the chief
physician logs onto PAS in order to check laboratory results. The laboratory
system and PAS are distinct, integrated information systems with compatible
data formats. The laboratory results are stored in the laboratory system but
can also be accessed from PAS. The laboratory results are uniquely given,
regardless of which information system you use to access them. In fact, laboratory
values are regarded as “facts” as demonstrated in the last quotes of the last
section.

Successful integration of laboratory values, however,
presupposes that it is possible to identify information related to the same
patient from one system to the next. Normally, this requires conformity in
demographic data (name, date of birth and personal identity number). An example
of this is from the Outpatient clinic (section 4.1) where only one set of
demographic data is stored as DocuLiveEPR imports this from PAS.

6.Conclusion

In terms of analysing how (lack of) integration influences
conditions for and contents of collaborative work, the two situations involving
related but not identical information (dubbed supplementary and ambiguity) are
the essential ones. Counter-intuitively for many, they underscore how
collaboration is undermined by centralised, “seamless” integration.
Supplementary (non-integrated, related but not identical) information fosters
what Boland and Tenkasi (1995) call perspective taking, the backbone of the
mutual understanding that underpins collaboration, communication and
coordination.

Ambiguity (integrated, related but not identical)
information plays a different but equally important role in promoting robust,
collaborative work arrangements. In striving to eliminate ambiguity, one
introduces a number of dependencies between communities of practise that imply
considerable – and largely unanticipated – additional work. Ironically, tighter
integration in these cases, aimed at fostering collaboration, end up
(unintentionally!) producing additional work in stead (Beck, 1992).

The ideal of ”seamlessly” integrated hospital information
systems relies on unwarranted purifications. An analysis of how users cope with
duplicated, fragmented and related information provide guidelines for design.
Design and intervention strategies for EPR need to balance on a tightrope: on
the one hand, to avoid promoting unrealistic, futuristic aspirations, overly
emphasising the potential of the technology, and on the other hand, to move
beyond a description of the immense richness of medical practise that may
easily infuse the impression that any intervention would necessarily upset this
elaborate and delicate play. Intervention, then, need to take seriously the transformative
– not merely the “supportive” (Berg, 1999:391-393; Berg, 2000:500-501) –
aspects of EPRs but proceed evolutionary (Atkinson and Peel, 1998).

Acknowledgement

Earlier versions of this paper have been presented at
seminars and at IRIS 23 and have benefited from constructive comments. We are
also grateful for comments from Marc Berg, Ole Hanseth and members of the
Kvalis project (kvalis.ntnu.no) as well as the reviewers.

References

Atkinson, C.J. and
Peel, V.J. (1998): Transforming a Hospital through Growing, not Building an
Electronic Patient Record System. Methods
of Information in Medicine, vol. 37, pp. 285-293.

Barley, Steve
(1986): Technology as an occasion for structuring: evidence from observation of
CT scanners and the social order of radiology departments. Administrative Science Quarterly, vol. 31, pp. 78-108.

Berg, Marc (2000):
Lessons from a dinosaur: Mediating IS research through an analysis of the
medical record. Paper presented at IFIP
WG 8.2 Working Conference 2000: IS 2000: The Social and Organizational
Perspective on Research and Practice in Information Technology.

Pinch, T. and
Bijker, W. (1989): The social construction of facts and artifacts : or how the
sociology of science and the sociology of technology might benefit from each
other. In Bijker, W.; Hughes, T.P.; Pinch, T. (eds): The social construction of technological systems, pp. 17-50. MIT
Press.

Szolovits,
Peter et al. (1995): Multiplatform
Internet Access to Multimedia EMRS: Excerpts from the original collaborative
proposal to the National Library of Medicine. The W3 EMRS project, http://www.emrs.org/publications/

[1] The OMG
(Object Management Group)’s CORBA (common object request broker architecture)
is a wiring standard that enables communication among objects that are
programmed in different languages and supported by different operating systems
(Szyperski, 1999:22-23).

[2] COM
(component object model) is a standard maintained by the Microsoft dominated
Active Group, a part of the Open Group (Szyperski, 1999:23).

[3] The
Norwegian health care system is a predominantly public one with marginal
private services, mostly outpatient ones. There is a growing pressure,
supported by a set of targeted efforts, in transforming the budgeting of the
public health sector to a more production oriented mode, in an attempt to curb
rising expenditures. On a trial basis, the Government reimburse about 20% of
the hospitals’ expenditures based on a DRG (Diagnosis Related Groups) coded
account of their production. The health care sector is organised into three
levels: primary health care, small hospitals and five regional hospitals
(together with a couple of national ones). Our study covers two of the regional
hospitals.

[4] At one of
the two hospitals covered in our study, paper records are estimated to occupy
16 km of shelves. The number of distinct information systems at the two
hospitals is estimated to be 40-60 by the IT departments.

[5] The National
hospital and Ullevål – one of the largest hospitals in northern Europe - are
different with only 15% and 30%, respectively, installed.

[6] DocuLiveEPR
imports demographic data like name, date of birth and addresses from PAS. In
addition, the diagnostic and procedure codes may in principle be imported. This
is seldom used, however, as these codes are normally recorded in the patient
record before PAS. The integration mechanisms are not based on standards like
CORBA or COM, but are rather hardware and language dependent solutions.

[7]International Classification of
Diseases as worked out by the World Health Organization (WHO).

[8] NCSP is an
abbreviation for NOMESCO Classification of Surgical Procedures. The NOrdic
MEdico-Statistical Committee was set up in 1966, following a recommendation by
the Nordic Council. An aim of NOMESCO is to promote the coordination of health
statistics in the Nordic countries.

[9] DRG is short
for Diagnose Related Groups.
The DRG system divides hospitalised patients into groups on the basis of
diagnosis and treatment. Based on the hospital's operating costs, an expected
price per patient discharged is estimated.

[10] This
corresponds closely to the debates on fault tolerance as discussed in systems
theory. E.g. Perrow (1984) argues that breakdowns regularly occur in complex
industrial work systems but are usually efficiently repaired as a part of daily
work.

[11] This is
exactly the direction taken in the next version (v5.0) of DocuLiveEPR.